The threat non-communicable diseases (NCDs) poses in Nepal, especially in cities, will probably grow without a more forceful health response, say health experts.
“If we don’t start interventions now to control NCDs, the problem will be alarming as the situation is already dire,” Prakash Raj Regmi, chief cardiologist of Nepal’s largest hospital, Bir Hospital, told IRIN in Kathmandu.
An estimated 50 percent of all deaths in Nepal are caused by NCDs every year - 8 percent more than a decade ago, according to data compiled in 2011 by the World Health Organization (WHO); the top killers are cardiovascular disease, followed by diabetes, cancer, chronic respiratory disease and road accidents.
Up until recently, Nepal, like many other low and middle-income countries, struggled primarily with communicable disease killers including HIV, malaria, measles and tuberculosis. And while these and other infectious diseases still exact their fatal toll, it is increasingly high blood pressure, heart attacks and traffic accidents sending people to health centres.
Reckless drivers, poor maintenance of vehicles and even poorer roads help contribute to more than 10,000 injuries and nearly 2,000 deaths annually, according to the government.
Rajendra Koju, director of the one of the country’s most reputable teaching hospitals, the non-profit, non-governmental Dhulikhel Hospital, which serves the capital and surrounding areas, expressed concern about the growing number of adults with hypertension, a risk factor for metabolic syndrome (a combination of medical disorders increasing a person’s risk of heart disease and diabetes).
Based on studies he conducted in a number of the country’s urban municipalities, Koju estimated one third of the country’s population aged 18 and older suffer from hypertension, often a precursor of heart disease and diabetes.
The director listed as risk factors alcohol consumption and stress in the home as well as persistent political instability (a constitutional stalemate coupled with frequent changes in government) since the end of a decade-long armed conflict in 2006.
Among the hospital’s 15 million annual patient visits, Koju said the most common illnesses included cancer, diabetes, and heart disease - in addition to almost weekly suicide attempts.
While death looms for individuals stricken by an NCD, the financial burden falls on the whole family - and survivors as the case may be sometimes - according to a 2011 World Bank report on NCDs in South Asia.
Over 55 percent of out-of-pocket patient expenses for NCD treatment and care are financed by borrowing and sales of assets in Nepal, creating “significant” levels of financial burden, said the report. In Nepal less than 1 percent of the US$370 million 2012-2013 national health budget is allocated for NCD- related activities, according to the Department of Health Services (DOHS).
“The low-income families are the worst victims of the government’s poor priority on NCD,” Shiva Shrestha, senior official of local NGO Nepal Diabetic Society, told IRIN.
While public hospitals do not charge user fees, the waiting list can be long for specialized care. Two national non-profit networks, including the Nepal Diabetic Society (the other being a cancer society), help fill the gap. The country’s top endocrinologists and cardiologists provide treatment for diabetic patients at highly subsidized costs through the Nepal Diabetic Society, essentially volunteering their time.
“What the country needs is a massive health campaign to control the rise of NCDs in both the cities and villages,” Kishor Kumar Pradhananga, head of prevention at the country’s largest oncology centre, Bisweswar Prasad Koirala Memorial Hospital in Chitwan, 200km southwest of Kathmandu, told IRIN.
His main concern is the patients who seek treatment only when their cancer is at an advanced stage, which multiplies treatment costs, drains household resources and often reduces the chances of success, a trend noted globally in a report published by WHO in 2011.
“The problem is they will run out of money and soon can no longer afford treatment and it is the low-income families who will be the worst victims,” senior health official Garib Das Thakur, director of DOHS’s Epidemiology and Disease Control Division, told IRIN.
He explained that the country’s financial burden of communicable disease has reduced in recent years, making NCDs a top government priority now.
The government is planning to design NCD early treatment and prevention programmes in over 20 (yet to be designated) of the country’s 75 districts nationwide.
“This [NCD] problem will get even worse given the increasing stress on the families of high inflation, rapid urbanization and negative lifestyles of Nepali families,” DOHS Director-General Lakhan Sah told IRIN, referring to pollution in rapidly growing cities, tobacco use and unhealthy diets as some of the biggest culprits for NCDs.
In 2013 national inflation averaged 9.3 percent, up from 7 percent last year, according to the government.
Some 51 percent of men nationwide surveyed for the country’s most recent Demographic Health Survey in 2011 reported smoking, while 13 percent of women did.
In Nepal around 16,000 people die annually of tobacco related diseases (90 percent from lung cancer), according to Nepal Cancer Relief Society.
Can cities kill?
Nepal remains predominantly a rural country with only 17 percent of its population living in cities. This distribution also makes it one of the most rapidly urbanizing countries in the region with a nearly 6 percent annual growth in cities since the 1970s, according to a UN calculation cited in a World Bank report published earlier this year.
“People are eating more ready-made food instead of cooking freshly at home, they are exercising less and more people have vehicles and walk less. The worst part is huge consumption of alcohol and tobacco products,” said Koju about the country’s burgeoning (in number and also in size) urbanites.
A 2010 meta-study of surveys on obesity in Nepal concluded “urbanization is the major driving force behind obesity in Nepal”.
According to WHO, as of 2010 (the latest year for which data has been analysed) NCDs were responsible for 36 out of 57 million deaths worldwide, with more than 80 percent of these deaths happening in low and middle-income countries.
High-income countries had the highest proportion - 87 percent of all deaths were caused by NCDs. The proportions are lower in low-income countries (36 percent) and lower-middle income countries (56 percent).
In May 2013, WHO member countries agreed to a monitoring framework that includes nine voluntary targets on reducing physical inactivity, salt/sodium intake, harmful use of alcohol, tobacco use, high blood pressure, the rise in diabetes/obesity and deaths from cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, while boosting drug therapy and counselling to prevent heart attacks and strokes.